Anorexia nervosa is an eating disorder that occurs when a person refuses to eat an adequate amount of food or is unable to maintain a minimally healthy weight for their height—a body mass index below 18.5. Individuals with anorexia often have a distorted body image. Those with anorexia view themselves as fat or bulky in certain areas and have an intense fear of gaining weight or becoming fat.
In service of their distorted belief, they typically engage in severely restricting food intake. What they consume, how much, and under what conditions becomes a preoccupation and is often obsessive in nature. They may avoid what they perceive as high-caloric food and meals, picking out a few foods and eating those in minuscule quantities, or they may carefully weigh and portion any food. People with anorexia may repeatedly check their body weight and engage in techniques to control their weight, such as intense and compulsive exercise or abuse of laxatives, enemas, and diuretics. Girls with anorexia often experience a delayed onset of their first menstrual period, and most women with anorexia experience amenorrhea, or absence of menstrual periods, as fertility is highly dependent on body weight in females.
Anorexia nervosa is one of the three major types of feeding and eating disorders; the others are bulimia nervosa and binge eating disorder. Eating disorders frequently co-occur with other psychiatric disorders, such as depression, substance abuse, anxiety disorders, and borderline personality disorder. In addition, people who suffer from eating disorders can experience a wide range of physical health complications, such as loss of bone mineral density, anemia, heart conditions, and kidney failure, which can, in some cases, lead to death. Anorexia nervosa is the most lethal mental health disorder.
The DSM-5 classifies symptoms of anorexia nervosa as follows:
- Refusal to maintain body weight at or above a minimally normal weight for one's age and height
- Intense fear of gaining weight or becoming fat, even though one is underweight
- Disturbance in the way in which one's body weight or shape is experienced
- Undue influence of body weight or shape on self-evaluation
- Denial of the seriousness of low body weight.
Anorexia nervosa involves starving the body; individuals with the condition tend to suffer the physical effects of malnutrition. While emaciation may be the most obvious sign, they may also experience cold intolerance, lethargy, abdominal pain, constipation, low heart rate, and low blood pressure, among other medical complications.
In the United States, an estimated 0.9 percent of females and 0.3 percent of males suffer from anorexia nervosa in their lifetime. The condition is most prevalent among 15- to 19-year-old girls.
There are two main types of anorexia nervosa:
Restricting Type Anorexia Nervosa occurs when the primary method of weight loss involves dieting, fasting, and excessive exercising—and not engaging in any bingeing or purging behaviors for at least a three-month period.
Binge Eating/Purging Type Anorexia Nervosa occurs when the individual has engaged in episodes of bingeing or purging behavior, such as self-induced vomiting, misuse of laxatives, diuretics, or enemas.
Yes, people can have atypical anorexia nervosa, which involves all of the same symptoms as classic anorexia except that the person’s body mass index doesn’t fall below 18.5 and they are not considered underweight or emaciated. They are still in danger of developing severe and even life-threatening health problems, however, and their eating disorder should be treated seriously and promptly.
Athletes are at a high risk of developing an eating disorder such as anorexia nervosa in order to be competitive in their sport. Parents, coaches, and other adults can be alert for warning signs, such as unusual or secretive eating habits, a preoccupation with being fat, evidence of purging (e.g., sores on the mouth or tongue caused by frequent vomiting), severe restriction of calories, food avoidance, irritability, and fatigue.
Anorexia nervosa and other eating disorders are commonly found in cultures and settings where thinness is seen as highly desirable. This is particularly the case in post-industrialized, high-income countries where fashion trends, sales campaigns, and media often present thinness as a desirable or typical trait. Some activities and professions, such as modeling and athletics, may promote a goal of unusual leanness (more than is required for health) in order to do well.
The onset of an eating disorder can also be associated with a stressful life event. For young adults, leaving home for college can be such an event. For older adults, other life transitions—returning to work after raising a family, finding a new job, separation or divorce—can precipitate symptoms of an eating disorder.
Temperamental factors, such as perfectionism and obsessional traits in childhood, are also associated with eating disorders.
Due to the increased prevalence of anorexia among first-degree relatives of those with the disorder, as well as in identical twins (relative to fraternal twins), biology and heredity seem to play an important role in risk of developing the disorder.
Appetite is, of course, a basic instrument of survival. It should come as no surprise that the basic biology of appetite is extraordinarily complex, regulated by many mechanisms affecting many body systems. Science is still plumbing all the effects of its alteration by prolonged overeating, on the one hand, and starvation, on the other. One hope is that such research will lead to new pharmacologic treatments for eating disorders. Scientists suspect that multiple genes may interact with environmental and other factors to influence the risk of developing these illnesses.
Anorexia nervosa is not all about food. Key risk factors for developing anorexia nervosa may include low self-esteem; poor relationships with one’s parents; physical, verbal, or emotional abuse; trauma; substance abuse; a perfectionistic or obsessive personality; and genetics, among others.
Research suggests that people who use social media especially frequently are more likely than others to develop an eating disorder such as anorexia nervosa. The danger is particularly high for adolescents, both girls and boys. Parents who are aware of the connection between social media use and eating disorders can be alert to the risk, recognize when it might be affecting their child, and get help as soon as possible.
If left untreated, anorexia may lead to osteoporosis, cardiac problems, infertility, depression, relationship difficulties, suicide, and even death from medical complications. Anorexia carries the highest death rate of any psychiatric condition.
Because of their complexity, eating disorders require a comprehensive treatment plan involving medical care and monitoring, psychosocial interventions, nutritional counseling, and, when appropriate, medication management. Counseling and therapy, coupled with medical attention to health and nutritional needs are important aspects of treatment. The sooner the disorder is identified and diagnosed, the better the chances for treatment and successful outcomes.
Treatment of anorexia involves three main goals:
- Restoring weight lost as a result of severe dieting and purging
- Treating psychological disturbances associated with body image distortions
- Achieving either long-term remission and rehabilitation or full recovery.
When deprived of the essential nutrients it needs, the human body can become malnourished no matter what the number on the scale says. As a result, when recovering from anorexia nervosa, patients need to embrace healthy nutrition and to gain weight, which can be an emotionally taxing process. Under the supervision of doctors and nutritionists, people in recovery from anorexia learn to consume enough calories to gain weight over the course of months or even years until they reach a healthy set point for their body. In the process, their blood pressure, heart rate, and temperature gradually return to normal levels. Importantly, females resume their menses (if applicable). In the course of recovery, mood of patients improves, they develop a healthier relationship with food, and they begin enjoying socializing and other activities.
Therapy is typically necessary to uncover factors underlying fears about eating and gaining weight as well to help individuals work through issues related to body image, self-esteem, control, and perfectionism. Cognitive Behavioral Therapy (CBT) is considered an effective form of therapy for eating disorders. It is time-limited and focused in nature, helping individuals to see the links between their thoughts, beliefs, and behaviors. CBT also involves building a tolerance for the discomfort and distress surrounding food that is common to anorexia patients. Such therapy helps to normalize eating patterns and encourage behaviors that support gaining healthy weight. CBT can shed light on dysfunctional thought patterns and negative attitudes and beliefs about food and eating that promote body shame and poor esteem.
Family therapy is also considered to be an effective way to treat anorexia nervosa as well as other eating disorders. The "Maudsley Method" is a form of family therapy in which parents become active agents supporting their child’s recovery. Developed at the Maudsley Hospital in London in 1985, the approach emphasizes that parents be calm, supportive, and consistent in the feeding of the child or adolescent with eating disordered behavior.
The role of medications in treating eating disorders is limited. Antidepressants or other psychiatric medications may be warranted to treat co-existing disorders, such as depression or anxiety. When a person's eating disorder is severe enough to be life-threatening or causes severe psychological or behavioral problems, inpatient or residential treatment may be recommended.
Not yet. There are some drugs normally prescribed for other conditions—such as the antipsychotic agents olanzapine and aripiprazole and the cannabinoid dronabinol, used to treat the nausea and vomiting associated with chemotherapy—that may be used off-label to promote weight gain. However, they frequently meet with resistance from patients, whose greatest fear is putting on weight and “being fat.” The drugs typically work by increasing hunger signals in the body and encouraging patients to eat more; however, they don’t always work with anorexia patients, who are used to feeling and ignoring hunger signals.
When an individual starves their body, their metabolism slows down in response; it is an essential biological defense mechanism meant to conserve energy and preserve life. In most cases, as a person increases their caloric intake, a process called "refeeding," their metabolism starts to speed up in response. Recovering from anorexia is difficult but possible, particularly with the support of a trained therapist and nutritional counseling.
Individuals who develop anorexia nervosa tend to have high levels of harm-avoidance and are prone to worrying. Learning healthy ways to cope with stress can be valuable. Anorexia involves rigid control, so it can be helpful to encourage psychological flexibility and spontaneity during treatment. Greater self-directedness can help people examine the underlying causes of their eating disorder and take an active role in planning solutions.